Feasibility of MHealth Interventions towards Promoting HIV Self-testing Uptake in Sub-Saharan Africa: A Systematic Review of Literature

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I. INTRODUCTION
Globally, as of the end of 2021, approximately 38.4 million individuals were living with the Human Immunodeficiency Virus (HIV), with two-thirds (25.6 million) of them disproportionately within Sub-Saharan Africa (SSA) (1,2).Although testing for HIV is a crucial first step to engaging HIV treatment by infected persons (3,4), one-fifth of those aged 15-64 in SSA remain undiagnosed despite the spread of HIV testing services (HTS) (5).HIV self-testing (HIVST) is a novel method for individuals to screen for HIV at their convenience using blood or oral fluid rapid diagnostic tests (6,7).Compared to conventional facility-based HIV testing, HIVST has the potential to address barriers to existing HIV testing uptake such as stigma and confidentiality concerns by serving as an entry point for HIV testing and thereby increasing access to HIV testing for populations that are hard to reach (8)(9)(10)(11).Given the potential of HIVST, the World Health Organization (WHO) in 2016 endorsed the utilization of HIVST as an alternative to conventional facilitybased testing (12)(13)(14).
Although studies have indicated that HIVST is generally well-received and feasible among high-risk groups who may not otherwise test (15,16), the reported uptake of HIVST is quite variable within different populations (17,18).Factors such as the independence of HIVST present challenges about users' self-efficacy in performing and interpreting the self-test results (19)(20)(21).Furthermore, since self-testing for HIV does not offer a conclusive diagnosis, individuals who get a positive self-test result are MHealth integration in HIVST is emerging, and research has shown growing interest in it because of the potential to address some of the challenges associated with self-testing, which is necessary to promote HIVST uptake and crucial for an effective roll-out (26,(31)(32).Existing reviews of mHealth-supported HIV testing studies have largely focused on conventional HIV testing (33,34).When they were focused on HIV self-testing, they spanned a wide range of digital technology, were not restricted to mHealth (26,(35)(36), were limited to specific populations, such as transgender people or men who have sex with men (MSM) (36), or were nonfocused within SSA (28).
While mHealth support for HIVST is expanding, there is a knowledge gap about which mHealth support approaches have been feasible to promote the uptake of HIVST in SSA.Given the need to close this gap, the researcher did a review of evidence from SSA on HIV self-testing with mHealth supports.This systematic review's objective was to synthesize evidence that summarizes existing efforts that leverage mHealth to promote HIVST uptake within sub-Saharan Africa and their feasibility, without limits on study populations or outcomes.The review has the potential to provide directions for future study and practice in this developing area.

II. METHODS
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) framework (37) was followed for conducting this systematic review.A comprehensive search for literature that promoted HIVST uptake in SSA was conducted and the feasibility of any mHealth technology used (phone calls, short message service (SMS), mobile applications(apps)), was assessed.

A.
Eligibility criteria Given that mHealth for HIVST promotion is quite novel, we included all quantitative studies [randomized controlled trials (RCTs), quasi-experimental or observational studies] that assessed any mHealth utilized for HIV self-test, reported feasibility outcomes, and were carried out in any country in sub-Saharan Africa.Studies without a focus on HIVST or did not include or evaluate an mHealth component were excluded.Trial protocols and review articles were also not included in this review.All studies had to include a mobile health component either completely or partially in the HIVST process, whether it was for HIV self-test delivery, its administration, test result interpretation, reporting of testing outcomes, linking to care, or follow up and were excluded if the mHealth component was not directly related to promoting HIVST uptake.

B.
Databases search A systematic search of scholarly literature published in English between January 1, 2010 and March 1, 2023 was undertaken using PubMed, SCOPUS, and CINAHL.Google Scholar and the bibliographies of studies that were retrieved were also reviewed for additional relevant citations.The search strategy combined relevant search phrases and utilized a combination of terms relating to HIV, self-testing, mobile health technology, and sub-Saharan Africa.
The search strategy used for PubMed combined the following search phrases: HIV OR "human immunodeficiency virus" OR "acquired immunodeficiency syndrome") AND (self-testing* OR self-sample OR "home test*" OR "home-based test*") AND ("mobile health technology" OR mHealth OR "mobile health" OR "mobile phone*" OR "mobile devices" OR "mobile apps" OR "cell

C. Data abstraction
Data was abstracted for geographical location, study design, target population, study period, sample size, type of mHealth HIVST support (mobile apps, SMS, phone call), non-mHealth add-on, study objective, intervention description, study results (feasibility and its associated metrics), author conclusion, and recommendations for research or practice (Table 1).

D.
Summary measure The summary measure used to assess HIVST with mHealth support was feasibility, which is a distinct implementation outcome and is defined as the convenience and extent of successful use of HIVST with mHealth (26,38).Metrics for feasibility include proportions of HIVST uptake, assisted testing, supervised testing, response to mHealth, error in mHealth, or retention on mHealth.

E.
Risk of bias The quality of clinical trials and observational studies was evaluated using the Cochrane Risk of Bias Tool (39).For cohort studies, the Newcastle-Ottawa Scale (40) was utilized while an adapted version of the Newcastle Ottawa scale (41) was used for crosssectional studies.

III. RESULTS
Of the 202 studies that were initially identified, 37 records were evaluated for eligibility, and 11 articles met the specified inclusion criteria, making them a part of this review (Figure 1).

C.
Reported metrics within feasibility Several metrics, including HIV self-test uptake, retention on mHealth, response rate, error rates, assisted testing request rates, and supervised self-testing choice rates, were used to report feasibility.Most studies reported one or more feasibility metrics and HIVST uptake was the most common way (81.0%) of assessing feasibility.HIVST uptake was highest in app-based interventions (89.0-100.0%),20.3-99.2% in combined mHealth interventions (SMS, phone call, or app), 22.3% in phone call-based interventions, and 4.1% to 15.9% in SMS-based interventions.Fewer studies reported other feasibility metrics such as response rates (45.0%),retention in mHealth (18.0%), assistance rate (18.0%), supervised rate (18.0%), and error rates (9.0%).Linkage to care using mHealth was also reported in 45.0% of studies.
Feasibility metrics were inconsistently reported because definitions varied across studies.For example, one study defined retention rate on mHealth as the proportion of participants that completed the post-test survey (42), while another defined it as the proportion of participants retained at 1 and 3-month assessment time points (29).The heterogeneity in reported metrics therefore posed a challenge with results cohesion and precluded the pooling of a meta-analysis across studies.

D. Narrative syntheses SMS-based interventions:
Two of the three studies that used SMS-based interventions found statistically significant increases in HIVST uptake among FSWs [15.9% intervention vs. 6.1% controls, p = 0.001] (43) and male truckers [4.1% intervention vs. 1.3% controls, p = 0.002] (31).Both studies were RCTs carried out in Kenya to investigate whether informing irregular HIV testers about the availability of HIV self-test kits using three text message reminders, spaced one week apart would increase their HIV testing rates.Although both studies concluded that SMS-based interventions can promote HIV testing uptake among populations that are hard to reach, both the truckers and FSWs had very low testing rates (4.1% and 15.9%, respectively).Of note also was that most participants (70.0%-72.2%)opted for clinic-based HIVST which was supervised, while a few others (15.0%-66.7%)who tested at home requested assistance.In contrast to HIVST uptake rates that was reported in the RCTs, Drake et al. (44) in a cohort study that assessed the use of SMS to report male partner HIVST results among Kenyan women seeking pregnancy-related health services (N = 486) reported feasibility as the response rate that can be attributed to SMS-based interventions.The study showed that text messages substantially increased HIVST results collection for women who had scheduled follow-up visits (RR = 1.48, 95%, [CI 1.32-1.64]), in addition to 82 (94%) more reports from women who didn't.SMS responses were further reported to have captured 68.5% (102/149) of all the HIVST outcomes evaluated for women in the survey, indicating a well above-average feasibility on HIVST outcomes.The study concluded that women who sought reproductive health services were willing and able to disclose sensitive HIVST outcomes via SMS.

App-based interventions:
Selection biases resulting from the use of non-randomized control trial designs limited the four studies (5,21,42,45) that evaluated mobile app-based interventions.Three out of the four studies employed HIVST-specific apps that were designed specifically for the studies.Only one study utilized an existing mobile app (Telegram) infused with a chatbot (Nolwazi_bot).All studies used the apps to guide participants through the testing process and result interpretation using picture or video-aided information.The apps also provided a platform for self-reporting the HIVST results.HIVST uptake was high (89.0%-100%)across most app-supported mHealth studies in persons aged 18 years or older, within or outside clinic settings (5,21,45).
The study by Gous et al. (21) conducted among adults (N= 300) in South Africa demonstrated that most participants accurately completed HIVST (267; 89.0%) and captured all their information on the HIVST-specific app (210; 78.7%).Notably, few participants (26; 8.7%) had trouble using the app-based instructions for self-testing and submitting the test picture.Participants suggested multimedia supplements, more languages, simplified instructions, and a minimally sized app to make the app easier to use.Another study in South Africa showed that when mHealth supported HIVST was used, the healthcare facility recorded a 25% increase in HIV testing among clinic attendees compared to the pre-mHealth supported HIVST study period (14.5% vs 19.9%; P < 0.001) (45).Apart from the high HIVST uptake reported in most app-supported studies, the study that utilized a non-HIVST-specific app infused with a chatbot (5) reported that majority of the participants (95; 79.2%) said their experience while testing for HIV under a chatbot guidance was significantly better than it was with a human counselor.Additionally, all 21 (17.5%)participants from the non-HIVST-specific app study, who self-tested positive for HIV were referred for confirmatory HIV testing and care through the app.
In contrast, Fischer et al. (42), in another study conducted among individuals who were unlikely to self-seek HIV testing from traditional facility-based testing (N = 751), found that although most participants (70.7%) were able to log into the HIV-specific app, below average received pre-test counseling (39.3%) or self-reported their HIVST results via the app (22.4%).Some participants mentioned data expenses, difficulty uploading results, and language barriers as challenges.Among the very few participants who completed the post-test survey (5.4%), the retention rate on the app was high (95.1%;39/41).

Phone call-based intervention:
With respect to call-based interventions supporting HIVST, only one study investigated its feasibility, and it reported significant increase in HIVST uptake.The multi-arm RCT conducted in Malawi (46) assessed the effect of HIVST alone or in combination with other interventions such as call reminders or financial incentives on the uptake of HIVST and linkage to care or prevention among male partners of antenatal care clinic attendees (N = 2,349).

Combined mHealth Strategies:
Three studies used combined mHealth strategies (SMS, app, and call).They harnessed the strength of multiple mHealth platforms to support users with information on HIVST usage, result interpretation, platforms for reporting test results, and, in some cases, real-time help for ordering HIVST kits.Feasibility was reported as HIVST uptake and was found to be high at 78.9%-99.2% in the observational studies (29,47) but low in the RCT (20.3%) (48).In a cross-sectional study conducted among at-risk Ugandan adults (N = 95) who were engaged in a three month HIVST engagement project (HiSTEP), which consisted of text messages, a telehealth center, and a self-test kit (29), HIVST uptake was 78.9% by the 3-month assessment.Furthermore, retention on mHealth was higher (94%) at 3-month time points relative to 1-month (66%) time points, indicating good feasibility.While the use of a combined mHealth approach was feasible in this population, follow-up calls conducted 2 weeks after ordering HIVST to determine kit usage and test results of participants may have influenced higher levels of retention at the 3-month assessment time points relative to 1-month.Only one participant tested positive for HIV and he was linked to care (100%) successfully via the mHealth platform.
Similarly, of 251 health care workers (HCWs) in an unsupervised but synergized strategy that used the internet, public health counselors, and mobile phones in South Africa (47), most participants (99.2%) completed HIVST conduct and interpretation successfully.Of those, nine were found to be seropositive after confirmatory tests and were linked to care through mobile phones and confidential text messaging within 24 hours.While combined mHealth strategies were highly feasible to promote HIVST and facilitated linkage to care by HCWs, the fact that this population is better informed about the consequences of their health choices may have contributed to the study's feasibility.Unlike most participants (91.2%; 229/251) rating of the mHealth supported HIVST as beneficial because of the privacy it offered, when it came to counselling, the majority of participants preferred face-to-face counseling (68.4%, 160/234) over technology-enabled counseling (40.6%, 95/234).
Contrary to the high feasibility reported in the observational studies above, Phatsoane Gaven et al. ( 48), in a pilot RCT that assessed the utility of SMS prompts or calls to encourage self-reporting of HIVST results and linkage into care among seropositive testers, reported low self-reporting of HIVST uptake (25.3%).Nonetheless, most respondents (64.9%; 204/314) who reported a positive HIV result reported linkage or intention to link to care, using the mHealth platforms.Of note however, was that voice calls resulted in 1.9 times more responses regarding HIVST usage and 2.2 times more self-reported HIV statuses compared to SMS.The authors concluded that although the study provided evidence that combined mHealth strategies could facilitate engagement and communication with HIVST users, the low self-reporting of HIVST results observed with SMS and voice calls in this study necessitates the need for future studies evaluating which mHealth tools are better suited to self-report HIVST outcomes for these adult participants.

E.
Assessment of study quality The summary of Cochrane risk of bias is presented in Figure 3. Majority of the RCTs adequately addressed incomplete outcome data, and selective reporting.Performance and detection bias were however high because blinding of participants and outcome assessments were not clearly described.There was also knowledge of the allocated interventions by participants or outcome accessors in almost all studies.The evaluation of observational studies quality, assessed using the Newcastle-Ottawa Scale, is detailed in Table I, and scores ranged from 4 to 6.   IV.DISCUSSION Although there has been a significant increase in the use of mHealth strategies, this review identified only 11 empirical studies that evaluated the feasibility of mHealth interventions aimed at promoting HIV self-testing uptake within sub-Saharan Africa.Of the studies identified, a wide range of mHealth interventions were employed, including mobile applications, SMS, calls, and combined mHealth approaches.Heterogeneity in the types of mHealth interventions and in how feasibility metrics were reported, made direct comparison of studies and robust critical evaluation across the different mHealth interventions challenging.This was however not surprising as some of the studies reviewed had reported that there were no validated universal measures for determining and subsequently reporting the feasibility of mHealth for HIVST (5,21).
There was also limited published research that specifically focused on populations in sub-Saharan Africa who are disproportionately affected by HIV (31,43).Furthermore, there were geographical gaps in the distribution of these studies, with half of them (50%) conducted in South Africa, thereby limiting the generalizability of the results to other regions within SSA.Additionally, there were methodological gaps in the studies, as most of them were observational pilot studies with small sample sizes.with most studies being observational pilot studies and with small sample sizes, thereby limiting the quality of the available evidence.This limitation impairs the overall quality of the available evidence.Furthermore, despite the ubiquitous presence and acceptability of readily available and commonly inherent phone apps such as WhatsApp (49), their use and effectiveness in promoting HIVST uptake in SSA are yet to be largely explored because HIVST-specific apps were mostly reported as being used in reviewed articles (21,42).
Evidence concerning the advantages of mHealth-supported HIV self-testing in sub-Saharan Africa was reported in nearly all the studies.According to some authors, mHealth was a feasible way of notifying individuals about the availability of HIV self-testing (31,43).MHealth also supported HIVST by providing information for HIVST use, support through the testing process, afforded confidentiality and privacy through unsupervised self-testing strategy, provided a platform for reporting test outcomes, upload pictures of HIVST results and increased HIVST uptake (5,21,42,45).Specifically, when SMS were used to support HIVST, there was evidence that SMS was effective in reporting the results of HIV self-testing.As a result, SMS may provide an appropriate platform to report HIVST outcomes that happen at home, which may lessen the burden and constraints of the health system associated with in-person visits (44).Although the feasibility of SMS to self-report HIV outcomes affirms previous research (50), the main limitation of SMS-based interventions is reliance on self-reported information because it can be influenced by social desirability bias particularly if there are no built-in checks to verify reported outcomes.Additionally, the review also provided evidence of significantly increased HIVST uptake following SMS notifications (31,43).However, the low proportion of HIVST uptake reported in the intervention arm across the studies (4.1%-15.9%),which may have resulted from the deliberate selection of individuals who seldom test for HIV, hampers the feasibility of this approach.Of note, however, is that the finding of small effects with simple SMS-based reminders aligns with results of a previous systematic review (27).These findings may not be unconnected to the limitations of SMS, such as character limits.
Furthermore, in the SMS-based intervention studies, it appeared that self-testers had less confidence in their self-efficacy to selftest because more participants opted for clinic-based self-testing with supervision, and of those who chose home use, above average still requested assistance with self-testing.This might indicate that although SMS-based mHealth interventions can be a valuable means to enlighten people about HIVST and subsequently increase its demand, they are not sufficient to support users through selftesting; hence, they may not represent the ideal mHealth strategy needed to promote testing uptake among hard-to-reach populations like male truckers and FSWs.To further promote HIVST uptake, authors suggested that future studies might explore whether providing participants with resources such as videos reiterating HIVST instructions and guidance, through a combination of SMS and other mHealth platforms that support multimedia messaging, leads to increased HIVST uptake.
Regarding studies that were mobile app-based, the lack of systematically assigned comparator groups in all the studies precluded determining if the high HIVST uptake observed in most studies resulted from the intervention or other contextual variables.Nonetheless, reviewed articles provided evidence that mobile apps may be a feasible way to provide counseling, information for HIVST use, prompt users to self-report test results, and upload pictures of HIVST results for confirmation to limit social desirability bias (5,21,42,45).This was because mobile apps supported adult participants through pretest counseling and offered a discreet option of learning to self-testers through the provision of picture-assisted self-test information for use (21,45)  Additionally, mobile apps enabled the collection of HIV self-testing data into a central database for monitoring and evaluation (21).Furthermore, errors reported by some participants while using the HIVST-specific apps and users suggestions provided key insights into desired areas of improvement by app users.Areas where improvements were desired were with multimedia supplements, additional languages, simplified instructions for use, data costs, and reducing the mobile app size.The review evidence implied that users were accepting of HIVST-specific apps if they were cost-effective, minimally sized, of low-literacy technology, and multimediaaided.Although the only non-HIVST specific app (telegram) that was evaluated reported 100% HIVST uptake when supported with a chatbot, the small sample size used hampers the generalizability of the study findings (5).Participant attrition while using appbased platforms, might also be a concern.This is because one app-based study (42) reported a low retention rate of 5.5% (41/751) for participants who completed a post-test survey.
When combined mHealth strategies were used, they demonstrated high HIVST uptake (78.9%-99.2%)(29,47) and above-average (64.9%-100%) linkage to confirmatory tests and care for participants (47,48).Of note, however, was that one of the two studies that reported a high HIVST uptake incorporated a non-mHealth add-in of in-person self-testing assistance.The non-mHealth add-in may have influenced HIVST uptake, but the study's use of an observational study design precluded the comparative evaluation of the effect of the non-mHealth add-in on the reported HIVST uptake (47).Conversely, this review's findings indicate that less is known regarding the most effective combined mHealth strategies to promote HIVST uptake.As more studies using combined mHealth interventions emerge, it will be critical to use rigorous study designs that can satisfactorily establish causality as this is essential to wholly assess the feasibility and effect of combined mHealth strategies on HIVST uptake.
The only call-based intervention significantly increased HIVST uptake relative to conventional HIV testing and HIVST study arms in a RCT (46), but the low proportion of observed HIVST uptake (22.3%) raises concerns about the adequacy of phone call reminders as the ideal strategy for male partners of antenatal clinic attendees.The cost-effectiveness of phone-based interventions is also an important factor to consider especially in resource-constrained environments like low-and middle-income countries where HIV prevalence is high.
Concerning the linkage of HIV self-testers who had a positive HIVST result to care, while 7 of the 11 reviewed articles reported on linkage, only 5 used mHealth platforms to link HIV self-testers to care.The reported linkage rates via mHealth platforms varied between 64.9% and 100% across the studies (5,29,(46)(47)(48).Notably, mobile apps and combined mHealth platforms demonstrated promising potential for achieving linkage to care, as they mostly reported 100% linkage for participants.Interestingly, studies that exclusively employed SMS as the mHealth platform did not report linkage to care for individuals who self-tested positive despite linkage to care being a crucial part of the HIVST approach (52).Additionally, in the two studies (46,48) that employed experimental study designs and reported on linkage, it was not stated if mHealth significantly improved linkage to care for persons whose self-test results were positive for HIV in the mHealth intervention group relative to control groups.This leaves a knowledge gap as to the effect of mHealth on linkage to care.Of note was the reporting of linkage to care varied among the studies as it included different aspects, such as referral for confirmatory testing, intention to link to care or ART initiation.Consequently, comparing the results across studies becomes challenging.Notwithstanding, the limited evidence about the impact of mHealth on linkage to care for HIVST in SSA, the available information suggests that mHealth may be a viable option to support the utilization of HIVST in the region.

V. POTENTIAL DIRECTIONS FOR FUTURE RESEARCH
More studies within each category of mobile technology domain are recommended to allow for critical evaluation of the literature within each mHealth type, which will guide the successful planning and implementation of future HIV self-testing programs by relevant stakeholders.Specifically, future app-based research should also prioritize higher-quality studies such as RCTs with a larger sample size, and conducted among diverse populations to provide more evidence of mobile apps feasibility in promoting HIVST uptake in SSA.Future studies may also benefit from research targeted at improving participant retention on mobile apps to limit the high attrition rate of participants reported in one of the app-based studies.Also, when HIVST-specific app is the intervention choice, stakeholders should invest in the development of minimally sized, user-friendly, culturally appropriate, and cost-effective apps.The apps should also require low literacy, allow for multimedia incorporation, additional languages, and simplified instructions so as to endear them to end users and ultimately promote HIV self-testing uptake.Furthermore, other readily available and commonly inherent phone apps with which most people are already familiar, such as WhatsApp, should be used and evaluated for their feasibility in promoting HIVST uptake in sub-Saharan Africa.
Although SMS and phone calls significantly improved HIVST uptake, comparative studies evaluating their effectiveness and cost effectiveness against other mHealth, such as apps, need further investigation.Future studies would benefit from larger sample sizes because the small sample sizes used in the majority of the reviewed articles limit the generalizability of the study findings.It is also recommended that more primary studies be carried out in key populations, such as Men who have Sex with Men or Female Sex Workers, whose prevalence of HIV is higher (17,53) and are unlikely to seek facility-based HIV testing (51).We also recommended that more primary research be conducted in more countries within the SSA sub-region so as to evaluate which mHealth support strategies for HIVST are best suited within these localities.Concerning linkage to care, future research should explore the most efficient mHealth platforms suitable for linkage to care following HIVST kits usage by target populations.Lastly, future studies should invest in a review of relevant literature to develop uniform indicators for reporting and evaluating the feasibility metrics for mHealth interventions in order to reduce heterogeneity in reporting feasibility outcomes.

VI. LIMITATIONS
As the evidence in this review spans mHealth-supported HIVST interventions written in English, the review may have excluded some relevant articles not written in English.Additionally, as only quantitative studies were included in the review, relevant information contained in qualitative studies may have been missed.The review was also confined to studies conducted within SSA, and study recommendations may not be generalizable globally.Also, these review results are only up to date as of March 2023.Despite these limitations, the researcher believes that the depth of evidence presented here summarizes existing endeavors that utilize mHealth to promote HIVST in SSA and their feasibility while also providing key insights into priority areas for future research on HIVST within this African sub-region.

VII. CONCLUSION
This systematic review synthesized evidence that summarizes existing published literature on the feasibility of utilizing mHealth to promote HIVST uptake in SSA.The volume of evidence presented regarding the utilization of mobile health for HIVST support in sub-Saharan Africa is an indication of growing interest in the potential that mobile phones offer towards improving access to and support for HIVST in low-resource settings.This systematic review reveals that mHealth supported HIV self-testing in various ways within and outside clinical settings through guidance for use, a platform for getting assistance with testing, self-reporting of self or partner results, linkage to confirmatory tests, and prompts for follow-up.Although different types of mHealth interventions were used to promote HIVST in various settings and study populations, this review demonstrates variable feasibility of the diverse mHealth (SMS, calls, apps, or combined mHealth) strategies to promote HIVST.More research is needed to investigate inconsistencies in feasibility results and determine the most feasible and efficient mHealth supported HIVST promotion strategies.Several evidence gaps also need to be addressed, including the need for more high-quality RCTs, studies that target key populations and are conducted in diverse sub-Saharan African countries.The exploration of the use of readily available and common mobile apps for mHealth interventions, as well as uniform indicators for reporting of feasibility metrics for mHealth interventions in order to standardize their reporting across all studies also need to be considered.

FUNDING
No external funding whatsoever.All the authors bore the cost of the publication.
Most participants (n=95/120, 79.2%) their HIV testing experience with the chatbot to be notably better to that with a human counselor and most (93/120, 77.5%) felt as if they were talking to a real person because of the tone and the choice of words of the bot.
Some participants however said that the chatbot was not as empathic as a human counselor (11, 9.2%), that the conversation was unidirectional (5%, 6/120) and making mistakes with it was easier (4, 3.3%)

Linkage to care
The researchers inferred that chatbots could promote HIVST due to its potential to mitigate certain barriers linked to HIVST uptake "cellular phones" OR "smart phone*" OR smartphone* OR SMS* OR text* OR "text messaging") AND ("sub Saharan Africa" OR Nigeria OR Kenya OR Zimbabwe OR Zambia OR Uganda OR Ghana OR South Africa OR Botswana).

Figure 1 .
Figure 1.Flowchart of the study selection process

Figure 3 .
Figure 3. Quality assessment of Randomized Control Trials =(yes); (-) = (No) 42).These resources subsequently aided in the self-administration of HIVST and the interpretation of results outside of healthcare settings.App-based interventions also boosted user engagement with gamification(42).The use of a mobile app as a support component for HIVST provided users outside of clinical settings the option of unsupervised HIV self-testing, which afforded users privacy without sacrificing access to relevant HIVST information that can boost testers self-efficacy.When mHealth was further used to support HIVST within clinical settings, it resulted in an almost twofold increase in the diagnosis of HIV among individuals aged18-35 (45).These possibilities offered by app-based interventions may make them particularly suitable for promoting HIVST among populations that are challenging to access (51).

Table Ⅰ : Characteristics of Studies That Assessed Mhealth Interventions Towards Promoting HIV Self-Testing Within Sub- Saharan Author, Year, [#Ref] Geographical location Study design Study population/sample size Study period Type of HIVST mHealth component Non mHealth add on
* Corresponding Author: Adaka, O. A.

Table II : Study Description and Findings in Assessing Mhealth Interventions Towards Promoting HIV Self-Testing Within Sub-Saharan Africa
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